Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions at selected hospitals of Sidama regional state, Ethiopia

Background COVID-19 causes worse outcomes and a higher mortality rate in adults with chronic medical conditions. In addition, the pandemic is influencing mental health and causing psychological distress in people with chronic medical illnesses. Objective To assess the knowledge, practice, and impact of COVID-19 on mental health among chronic disease patients at selected hospitals in Sidama regional state. Method A facility-based cross-sectional study was conducted. A total of 422 study subjects were enrolled in the study using a two-stage sampling technique. Data were coded and entered using Epi Data version 3.1 and exported to SPSS-20 for analysis. Descriptive analysis was used to present the data using tables and figures. Bivariate and multivariate logistic analyses were used to identify factors associated with the initiation of preventive behavior of COVID-19. Variables with a P-value of less than 0.25 in bivariate analysis were considered as candidate variables for multivariable analysis. The statistical significance was declared at a P-value less than 0.05. Result More than half 237 (56.2%, 95% CI: 50.7–60.9) of the study participants had good knowledge of COVID-19. The practice of preventive measures toward COVID-19 was found to be low (42.4%, 95% CI: 37.9–47.2). Being widowed (AOR = 0.31, 95% CI (0.10, 0.92)), secondary and above educational status (AOR = 2.21, 95% CI (1.01, 4.84)), urban residence (AOR = 2.33, 95% CI (1.30, 4.19)) and good knowledge (AOR = 4.87, 95% CI (2.96, 8.00)) were significantly associated with good practice. In addition, more than one-third of the study participants 37% (95% CI 32.7, 41.5) were experiencing anxiety. While more than a quarter of respondents 26.8% (95% CI 22.5, 31.5) had depression. Conclusion and recommendation Despite more than half of the participants had good knowledge, the prevention practice was low. Hence, multiple information dissemination strategies should be implemented continuously among chronic disease patients. In addition, the magnitude of concurrent depression and anxiety in the current study was high.

Introduction case identification, contact tracing, quarantine, and large-scale screening in vulnerable groups; controlling the spread of disease among high-risk groups must be one of the strategies of COVID-19 prevention practice [11]. Despite this, the majority of studies in Ethiopia focused on health professionals and the general population, rather than the vulnerable groups of chronic disease patients. The result of this study may help to direct the efforts and plans of public health authorities and media of the country for better and timely control of COVID-19. Thus, this study aimed to determine the knowledge and practice toward COVID-19, the prevalence of depression and anxiety during the COVID-19 pandemic, and the associated factors of good knowledge and practice among patients with chronic disease at 3 hospitals in the Sidama region.

Study area
The study was conducted in selected public hospitals in Sidama regional state. Sidama region is one of the regional states of Ethiopia with a population of more than 4 million, where more than 90% of the population lives in the rural part of the region. It has a total of 30 districts and 6 town administrations. It is located 272 km to the southeast of Addis Ababa and the region has a total area of 6,981.8 square kilometers. According to a 2018 estimate, the total population of the region was 4,294,730 of which 2,104,418 are females and 2,190,312 are males [12]. Currently, there are 16 public hospitals, 126 health centers, 531 health posts, 24 medium and 83 primary privates, and 7 NGO clinics [13].

Study design and population
A facility-based cross-sectional study was conducted from June 20 to July 30/2020. The source population of this study was all patients with chronic diseases (hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease) who attended the chronic disease follow-up clinic at three hospitals in the Sidama region. While the study population was all patients with chronic disease who attended the chronic disease follow-up clinics at three hospitals during the study period.

Inclusion and exclusion criteria
All chronic disease patients who were on follow-up at the selected hospitals during the study period were included. The study excluded chronic disease patients who were severely ill, had cognitive impairment, were younger than 18 years old, and health professionals.

Sample size determination
The minimum sample size required for the objectives of the study was calculated by using the single population proportion formula, using the following assumptions

Sampling procedure
The Sidama regional state has a total of 16 hospitals (2 general hospitals, 13 primary hospitals, and 1 comprehensive specialized hospital). Based on patient flows, 3 hospitals were selected purposively, and a sampling frame was prepared for each hospital based on the number of chronic disease patients in the last month who attend the chronic disease follow-up clinics. Based on one month of data, there were around 1376, 1100, and 900 chronic disease patients who attend the chronic disease follow-up clinic at Hawassa university comprehensive specialized hospital, Yirgalem general hospital, and Leku primary hospital respectively. A proportional sample to the number of patients at each hospital was allocated, and then the systematic sampling technique (K = 8) was used to select each study participant from their respective group.

Study variables
The dependent variables were knowledge and practice toward the COVID-19 pandemic. The independent variables were socio-demographic variables such as sex, age, place of residence, educational status, occupation, marital status, monthly income etc. . .

Data collection procedure and tool
Data was collected using a structured interviewer-administered questionnaire. The questionnaire was adapted from the WHO website and other relevant COVID-19 literature [14,15]. The questionnaire consisted of four parts (see S1 File). The first part included the socio-demographic characteristics of the study participants. The second part included 16 questions designed to assess the knowledge of COVID-19. The knowledge questions were answered with options Yes/No/I don't know. In the third part, 15 questions with Yes/No answer options were used to assess practice. Depression and anxiety were measured by the Hospital Anxiety and Depression Scale (HADS). This tool contains 14 items (seven for each) that are scored in Likert form from 0 to 3; giving a total of 21 points. The scale has been validated in different populations in Ethiopia [16]. Data were collected using 5 diploma nurses and supervised by three supervisors with bachelor's degrees in public health.

Data analysis procedure
The collected data were entered into Epi data version 3.1 and exported to the statistical package for social science (SPSS) version 20 for analysis. First descriptive analysis was carried out for each of the variables (including for the outcome variable knowledge and practice). A correct answer (Yes) for the knowledge question was assigned 1 point, and No/I don't know answer was assigned 0 points. The total knowledge score ranged from 0 to 16, Participants' overall knowledge was categorized using Bloom's cut-off point as Good if the score was between 80 and 100% (12.7-16 points), and Poor if the score was less than 79% (<12. 6 points) [15]. The correct answer for the practice question was assigned 1 point and an incorrect answer was assigned 0 point. The total practice score range from 0 to 15. The overall practice score was categorized using Bloom's cut-off point, as Good if the score was between 80 and 100% (12-15 points) and Poor if the score was less than 79%(< 11.9 points) [15].
Association between independent variables and dependent variables was assessed and its strength presents using odd ratio and 95% confidence interval. Binary logistic regression analysis was applied. All predictor variables that have an association in bivariable analysis with a pvalue < 0.25 were entered into a multivariable logistic regression model. In multivariable logistic regression analysis, those variables with a p-value � 0.05 were considered statistically significant.

Data quality control
The questionnaire was first prepared in English and then translated into Amharic version by a professional translator with a health background who was a native speaker of Amharic language and fluent in English. The backward translation from Amharic to English was done by an independent translator who was a native speaker of the source language and fluent in Amharic language. Consensus on the compatibility of forward and backward translation was assured before the actual data collection activities. Data collectors and supervisors were trained for two days by the principal investigator before the actual study commenced on the objectives of the study. As part of training, the data collection tools were pre-test in 5% of the total sample at Shashemene hospital (adjacent to the study area) before the actual data collection to check the questionnaire addressed the study variables, as well as to check the extent at which questions understood by the interviewee and to identify areas for modification and correction. The principal investigator and supervisors checked the completeness and consistency of the collected data and provided early feedback to the data collectors.
Each questioner was given a code before data entry to make data processing easier. In addition, the data entry format was prepared in Epi data software based on the pre-coded questionnaire. To reduce some errors during data entry, a check file was developed (to detect and refuse some data entry mistakes). Before conducting analysis in SPSS software, data cleaning was done to check for outliers, consistency, and to verify the skip pattern was followed. Furthermore, exploratory data analysis was performed to determine the levels of missing values and the presence of multi co-linearity.

Ethical consideration
Hawassa University's institutional review board granted ethical clearance under reference number IRB/293/12. Written informed consent was obtained from the study participant before their participation. Study participant's confidentiality and privacy were protected by excluding their names from the questionnaire and keeping their data safe in password locked computer throughout the whole process of research work. At the end of each interview, study participants received health education on COVID-19 signs and symptoms, transmission routes, and preventive measures.

Socio-demographic characteristics
A total of 422 participants were included in the study, which makes the response rate 100%. The median age of the respondents was 44 years with IQR of (33, 55) years old. Out of the total study participants, 230(54.5%) of them were married. From study participants, 114(27%) of them could not read and write while 164(38.9%) had above secondary educational status.
More than half (50.2%) of the participants were from urban areas. The average monthly income of study participants was 3451 (SD± 3003). About 114(27%) and 50(11.8%) were government and private employees respectively. More than one-third (33.9%) of the participants had a diagnosis of Diabetes mellitus, followed by Hypertension 88(20.9%) ( Table 1).

Knowledge of participants toward COVID-19
Out of 422 study participants, more than half (56.2%, 95% CI: 50.7-60.9) of them had a good knowledge of COVID-19, while the remaining 185 (43.8%) had poor knowledge. Most (93.8%) of the study participants were aware that the main clinical symptoms of the novel COVID-19 are fever, dry cough, shortness of breath, and myalgia. More than half (53.6%) of Table 1. Socio-demographic characteristics of chronic disease patients, at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

Variables
Frequency (

Participants practice toward COVID-19 prevention approach
More than half of the participants (57.6%, 95% CI: 52.8-62.1) had poor practice toward COVID-19 prevention methods. Only 179 (42.4%, 95% CI: 37.9-47.2) of the study participants had a good practice. Around 63.7% of the study participants practice physical distancing by remaining 6 feet or 2 meters from others all the time. The majority (77.3%) of respondents limit physical contact such as handshaking. More than two-thirds of participants (69.7%) touch their eyes, nose, and mouth frequently with unwashed hands (Table 3).

PLOS ONE
Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions

Prevalence of depression and anxiety among patients with chronic health problems during the COVID-19 pandemic
More than one-third of the study participants 37% (95% CI 32.7, 41.5) were experiencing anxiety. While depression affected more than a quarter of the respondents, 26.8% (95% CI 22.5, 31.5) (Fig 1).

Factors associated with good knowledge about COVID-19
During the initial bivariate analysis, age, marital status, educational status, place of residence, occupation and monthly income had a significant association with good knowledge at 0.25 Pvalue. But, after applying a multivariate logistic regression age, marital status, place of residence, and occupation remain in the final model associated with good knowledge at 0.05 Pvalue.
The odds of having good knowledge in the younger age group (18-39 years) were 2.36 times higher than in the older age group (>61 years). Participants in the study who were single had a 60% lower chance of having good knowledge than those who were married. The odds of having good knowledge in urban residents were 2.02 (1.15, 3.57) times higher than the counterpart (Table 4). Table 3. Preventive practice toward COVID-19 among chronic disease patients at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

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Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions

Factors associated with a good practice toward COVID-19 prevention approach
From the total variables entered into the multivariable regression, four variables namely marital status, educational status, place of residence, and knowledge about COVID-19 were found to be independently associated with good practice of COVID-19 prevention approaches among chronic disease patients at a P-value of <0.05. The study participants those who were divorced and widowed were 78% and 69% (AOR = 0.22 (0.07, 0.63) & AOR = 0.31 (0.10, 0.92))) less likely to practice COVID-19 prevention approaches appropriately as compared with married, respectively. Study participants with secondary and above educational status were 2.2 times (AOR = 2.21 (1.01, 4.84) more likely to practice goodly the COVID -19 prevention methods. The odds of good practice among urban study participants were 2.3 times (AOR = 2.33 (1.30, 4.19) higher than among rural study participants. Participants who had a good understanding of COVID-19 were 4.8 (AOR = 4.87 (2.96, 8.00) times more likely to have good practices (Table 5).

Discussion
As COVID-19 is causing a significant number of morbidity and mortality globally, putting preventive measures in action is critical to avert its impact. Improving the knowledge and practice of high-risk groups (like chronic ill patients) toward COVID-19 preventive measure are crucial for the effective prevention and control of COVID-19. Furthermore, the pandemic had an impact on the mental health of the entire population, particularly on high-risk groups. This study assessed the knowledge and practice toward COVID-19 and the mental health

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Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions impact of the pandemic (depression and anxiety) among chronic ill patients in three hospitals in the Sidama regional state.
Our finding indicates that there was a high prevalence of poor knowledge (43.8%) among chronically ill patients. This finding is higher than that of studies conducted in China and Kenya [18,19]. This difference might be because China and Kenya surveys included urban study participants, whereas our study included nearly half (49.8%) of study respondents from rural areas. In addition, another reason might be due to the fact that 82.4% of study participants held an academic degree or associate's degree or above in China. According to this study, younger age groups were more likely to have a good knowledge than the elders. This finding is supported by the study conducted in Egypt [20] and Chicago [21], which reported that younger respondents showed good knowledge. This might be due to the physiological changes during aging. As age increases, the visual performance and hearing ability get decrease. As a result, it is difficult to read and understand various health-related issues, resulting in a lack of knowledge. Urban residents were two times more likely to have good knowledge than rural residents. This finding is in line with the study conducted in Addis Zemen and China [15,18]. This is because of better access to the information in urban areas, where there is better access to online Media to update themselves about COVID-19. The vast majority of rural people may lack access to the Internet and social media and rely solely on television and radio for information; which may limit their ability to learn about the disease. A study conducted in Iran showed that participants who got their information from social media, scientific articles, and journals had significant higher knowledge of the disease as compared to news media users who had significantly lower knowledge regarding the transfer routes and groups at higher risk regarding COVID-19 [22]. In addition, the majorities of rural Ethiopians are illiterate and live far from the healthcare facilities where they can get health-related information.
In this study, government employee and private employees were around 5 times and 2 times more likely to have good knowledge than housewives, respectively. This is in line with the study conducted in Jimma [23]. This is because they had strict instructions about COVID-19 infection control and preventive measures at offices compared to housewives. A chance to have a better social network at the workplace might help them in obtaining information about COVID-19.
In this study, the prevalence of good COVID-19 practice among chronically ill patients was very low (42.4%), which was in line with a finding in Ethiopia [24]. However, it was lower than the finding in Saudi Arabia (81%) [25] and Rwanda (90%) [26]. The possible justification for this disparity might be knowledge differences in the study population, attitudes toward disease, different data collection periods, and the policy of countries toward COVID-19 prevention measures at the time of data collection.
The majority (82.5%) of study participants attend social gathering events and religious activities; however, in China, and Chicago, only a small number of study participants visit any crowded place [18,21]. This difference is due to the socio-cultural and religious differences in the study population. Measures taken by the government to prevent the transmission of COVID-19 may also be another possible difference. In response to the preventive measures being followed by the study participants, 73.3% claimed that they were using a face mask and 60% of participants said they were washing their hands with soaps and water frequently.
Study participants with secondary and above educational status were more likely to have a good practice toward COVID-19 prevention approaches than those with the educational status of unable to read and write. As with this finding, a study carried out in Iran and Adiss Zemen showed that a higher level of education was associated with a high practice of COVID-19 prevention [15,22]. People with better educational status have a better chance of acquiring information regarding the COVID-19 prevention techniques. In addition, different studies showed that educated people have positive attitudes regarding how people should behave toward COVID-19 [19,21,22]. Having adequate information regarding COVID-19 prevention techniques with a positive attitude toward it leads to good practice.
The odds of good practice among divorced and widowed were 78% and 69% less likely as compared to the married one. The finding agreed with a study conducted in Pakistan [27]. This might be because married people practice COVID-19 prevention practice as they feared the spread of the disease to their partner.
The odds of good practice among urban study participants were 2.3 times higher than among rural study participants. This finding is consistent with the study done in Jimma and China [18,23]. This might be as different studies showed that people from urban areas have a better knowledge of COVID-19 prevention, because health information that improves the knowledge and practice is becoming more accessible online, however it is not reachable to rural residents [28]. In addition, it might be due to the prevention actions set by governments being implemented well in urban areas as compared to rural.
Patients with good knowledge were more likely to practice well. This finding is in line with the study conducted in China, Adiss Zemen and Adiss Abeba [15,18,29]. This might be due to knowing the seriousness and infectiousness of the virus pushing them to practice the preventive measures.
The prevalence of depression (5.73%) and anxiety (32%) among patients living with a chronic medical condition in Ethiopia, before the emergence of COVID-19 [30] was found to be lower compared to the finding of the current study conducted amid the COVID-19 pandemic, which revealed a high prevalence of depression (26.8%) and anxiety (37%). The finding was lower as compared with the findings of Metu referral hospital, which reports 55.7% and 61.8% have depression and anxiety respectively [8]. This could be due to the time of data collection and the tool used to measure the variables.

Limitations of the study
The study has certain limitations; firstly respondents might give socially acceptable answers, for example, practice-related questions were collected through participants' responses rather than through observation of what they do. In addition, the cross-sectional nature of the study did not allow us to show the cause-effect relationship. Moreover, since the study was conducted in a health facility there is a possibility of bias as the underprivileged population may not have been able to participate in the study.

Conclusion
Insufficient knowledge about COVID-19 still exists among chronic disease patients, which could pose a barrier to good prevention practices. Age (younger age group), marital status, urban residence, and occupation of government employees were significantly associated with good knowledge. Secondary and above educational status, urban residence, and good knowledge were significantly associated with good practice related to COVID-19 prevention practice. In addition, the extent of co-occurring depression and anxiety in this study was high.
The minister of health, regional health bureau, zonal and district health offices should devise appropriate interventions to fill knowledge and practice gaps among chronic ill patients. Parallel to this, special attention should be given to those with low educational attainment who are unable to read or write, as well as the rural community. In patients with chronic health conditions, strategies for early detection and treatment of depression and anxiety should be developed. In addition, other studies should be conducted to identify the predictors of anxiety and depression. collectors, supervisors, and study participants. Finally, our special thanks go to Arsema Abebe for her guidance and support.